NORDIC HAMSTRING PROGRAM
Injury PreventionSport Med ‘18
January 26
Dave Wright CAT(c)
University of Guelph
Hamstring Injury Prevention
Injury Prevention: Evidence Based Literature
Hamstring injuries are the most common soccer-related muscle injury
Account for 37% of all soccer muscle injuries (Ekstrand J. et al, 2015)
Using the Nordic Hamstring Exercise in regular training reduced hamstring
injury incidence rates by 65%-70% demonstrating preventative effect in reducing
recurrent injuries (Peterson J. et al, 2011)
A random trial of using the Nordic Hamstring Exercise completed with
942 Danish soccer players resulted in:
59% less new, acute hamstring injuries with the 10 week controlled group
Re-injury rate was 86% lower in the same group (Peterson et al, 2008)
The peak muscle-tendinous force and strain for the hamstring muscle group
occurs during the terminal swing phase, just before ground contact (Thorborg et
al, 2012)
As a result, Thorborg et al recommended that eccentric muscle strength should be
performed at longer muscle-tendinous lengths representing movements and muscle
length occurring at both the knee and hip
What is the Nordic Hamstring Exercise?
Nordic Hamstring Technique Cues
Keep ankles firmly on ground or floor
Suggest to place roll under ankles to reduce pressure
stress applied to joint
Keep head, trunk, hips and thighs in a straight line
Bend from knees NOT hip or spine (knee flexion
technique)
Perform exercise slowly, under control, lowering body
as far as possible towards the ground or floor
Nordic Hamstring Exercise Benefits & Support
Evidence and research based eccentric hamstring injury prevention
exercise
Suitable for all patients and athletic abilities
Easy instruction for effective technique
No heavy equipment necessary only a soft surface
Bodyweight and gravity acts as load
Slow cadence with simple controlled movement
May perform independently or with a partner
Uses spine and hip extensors to stabilize trunk during exercise
Posterior load stabilizer assisting in minimizing translation during an
ACL mechanism of injury
Why use the Nordic Hamstring Exercise?
Well evidenced as hamstring injury prevention with
significant, supportive literature
Formally introduced in 2001 finding hamstring injuries
caused by strength deficits, notably eccentric strength
towards end range (Mjolsnes et al, 2004)
English textbook from year 1880 demonstrating Swedish
exercise methods…yet to be named Nordic Hamstring
Exercise?
“Old is new again” with Nordic Hamstring Curls seemingly
making a return…but did it really go away?
Recommended Frequency & Volume
Systematic, minimal and progressive increase in volume, reps
and load
Source: Mjolsnes et al 2004
Week Sessions/Week Sets Reps
1 1 2 5
2 2 2 6
3 3 3 6-8
4 3 3 8-10
5-10 3 3 12, 10, 8
Minimum Recommended Reps
BEGINNER
repetitions: 1 set (3 – 5 repetitions)
INTERMEDIATE
repetitions: 1 set (7 – 10 repetitions)
ADVANCED
repetitions: 1 set (minimum 12 – 15 repetitions)
Source: Mjolsnes et al 2004
Injury Prevention Protocol
Load increases as athlete can withstand the controlled, forward fall
Greatest eccentric benefit as hamstring muscle group lengthens closer to ground
When able to withstand the entire range of motion for 12 reps, increase load by adding speed to the starting phase of the motion
A partner may also increase loading further by pushing at the back of shoulders
Add the use of elastic cords to provide support and control for proper technique to end range for beginners
Source: Mjolsnes et al 2004
Assisted Nordic Hamstring Curl
Nordbord
Designed at University of Queensland, Australia
Youth Soccer Initiatives
FIFA 11+ injury preventative program
Developed by International experts from FIFA’s Medical Assessment and Research Centre (F-MARC), the Oslo Sports Trauma Research Center and the Santa Monica Orthopaedic and Sports Medicine Research Foundation
When incorporated into team warm-up, resulted in 11.5% fewer game injuries and 25.3% less injuries during training or practice (Bizzini, M., Junge, A., Dvorak, J., 2013)
Study: Barengo, N., Francisco Meneses-Echávez, J., Ramírez-Vélez, R., Cohen, D., The Impact of the FIFA 11+ Training Program on Injury Prevention in Football Players: A Systematic Review; Int. J. Environ. Res. Public Health 2014, 11(11), 11986-12000
International Professional Soccer
FCBarcelona “Muscle Injuries Clinical Guide 3.0” (January 2015)
First edition published in 2009
FCBarcelona and Aspetar Medical Staff
Why Not More Widely Used? Concern for Delayed Onset Muscle Soreness (DOMS)
Mjolsnes protocol progressively designed to minimize effects
Compliance
Program design recommends 6-10 week training periods
Current industry exercise approach is “functional” vs “isolation”
Players fail to maintain proper technique and load during full active range of motion
Cramping, dehydration a possibility?
Differentials: fatigue, sciatic nerve (Slump Test), lumbar spine, anterior pelvic tilt, poor gluteal muscle activation…
Open chain exercise
Inhibition: hamstring injury rehabilitation protocols too conservative?
Bilateral exercise rather than independent or single side exercise for muscle balance
Does not increase concentric hamstring strength during technique
Nordic Hamstring as Rehab Exercise
“If you think hamstring exercises must be
‘functional’, be aware that data shows
structure matters.”
“Examine the athlete, not the image of the
injured hamstring.” Kristian Thorborg PhD, Sports Orthopedic Research Centre -
Copenhagen
Lengthening Protocol
Source: Askling et al, 2014
Preventative Muscle Activations &
Stabilizers
Opposite arm/leg raise (50% gluteus maximus
activation prior to each leg lift):
Bridging/table top with leg lift:
(progress by extending leg on floor)
Implementation Techniques
Team or Group Applications:
Complete during dedicated gym sessions
Team or group circuit training combined with agility skills development or conditioning drills
Off-day training post warm up, mobility, flexibility and fascial release/foam roller techniques
Team or Individual off-season or LTD training programs
Incorporate FIFA 11+ as group warm up
Begin with only 1 session/week to a program maximum of 3 sessions/week as recommended by Mjolsnes chart
Perform in conjunction with spine and gluteal muscle patterns for global trunk stabilization and intrinsic muscle balance
References Ekstrand J, Hagglund M, Walden M. Epidemiology of Muscle Injuries in Professional Football (Soccer). Am J
Sports Med. 2011;39(6):1226-1232
Peterson J, Thorborg K, Bachmann Nielsen M, Budt-Jorgensen E, Holmich P. Preventative Effect of Eccentric Training on Acute Hamstring Injuries in men’s soccer; A Cluster-Randomized Controllecd Trial. Am J Sports Med. 2011;39(11):2296-2303
van der Horst N, Smits D-W, Petersen J, Goedhart E A, Backx F J.G. The Preventive Effect of the Nordic Hamstring Exercise on Hamstring Injuries in Amateur Soccer Players: A Randomized Controlled Trial. Am J Sports Med. 2015;43(6):7
Mjølsnes R, Arnason A, Osthagen T, et al. A 10-week randomized trial comparing eccentric vs. concentric hamstring strength training in well-trained soccer players. Scand J Med Sci Sports 2004;14:311–17.
Petersen J, Thorborg K, Nielsen MB, et al. Preventive effect of eccentric training on acute hamstring injuries in men's soccer: a cluster-randomized controlled trial. Am J Sports Med 2011;39:2296–303
FCBarcelona Muscle Injuries Clinical Guide 3.0; January 2015 in collaboration with Aspetar Medical Staff
Bizzini, M., Junge, A., Dvorak, J., (2013.) Implementation of he FIFA 11+ football warm up program: How to approach and convince the Football associations to invest in prevention. British journal of sports medicine, bjsports-2012-092124
Arnason A., Anderson TE, Holme I, et al. Prevention of hamstring strains in elite soccer: an intervention study. Scand J Med Sci Spors 2008; 18:40-8
Askling CM, Tengvar M, Thorstensson A. Acute hamstring injuries in Swedish elite football: a perspective randomized controlled clinical trial comparing two rehabilitation protocols. Br J Sports Med 2013;47;953-9
Ditroilo M, De Vito G, Delahunt E. Kinematic and electromyographic analysis of the Nordic Hamstring Exercise. 2013 Oct;23(5):1111-8
Timmins R, Porter K, Williams M, et al. Biceps femoris muscle architecture—the influence of previous injury. Br J Sports Med 2014;48:665–6
Sherry MA, Best TM. A comparison of 2 rehabilitation programs in the treatment of acute hamstring strains. J Orthop Sports Phys Ther2004;34:116–25
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Thank you
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